Pain in the gluteal region is a frequent complaint of patients seeking orthopedic care, but it is one of the least known subjects in the medical and orthopedic field. Evolution in the understanding of hip diseases and the use of endoscopic techniques have enabled a significant improvement in the quality of life of patients with gluteal pain. It is not uncommon for individuals with gluteal problems to undergo unsuccessful hip or spine joint surgical procedures. It is often difficult to determine the source of symptoms. In addition, lumbar spine and hip joint problems can coexist with glute problems.

One concept is fundamental to understanding gluteal pain: the hip is not just bone. Different tissues form the hip and gluteal region and may be a source of pain.

Gluteus Anatomy

The gluteus maximus muscle is the most superficial of the muscles of the gluteal region.

Deep to the gluteus maximus muscle is the deep gluteus space, where most pathologies of the gluteus region are located. Several nerve and vascular structures leave the pelvis and pass through the gluteal region before reaching the genitals or lower limb. The most important of these is the sciatic nerve, which in about 85% of people comes out below the piriformis muscle. The figure below illustrates the deep gluteal region after removal of the gluteus maximus muscle.

Deep to the gluteus maximus muscle is the deep gluteus space, where most pathologies of the gluteus region are located.  Several nerve and vascular structures leave the pelvis and pass through the gluteal region before reaching the genitals or lower limb.  The most important of these is the sciatic nerve, which in about 85% of people comes out below the piriformis muscle.  The figure below illustrates the deep gluteal region after removal of the gluteus maximus muscle.

Sciatic Nerve Compression – Piriformis Syndrome

The main cause of gluteal pain is sciatic nerve compression. This nerve can be compressed by bone, vascular structures, scars or muscles and tendons. The most common cause is piriformis muscle abnormality, present in 15% of the population. Thus, a portion of the piriform tendon passes through the sciatic nerve, squeezing it when the muscle is contracted or stretched.

The main symptoms are sitting pain and sciatica pain radiating to the thigh and leg. Patients usually abandon more intense physical activity and may have significantly reduced quality of life, especially considering chronic neuropathic pain. They can hardly sit for more than 20 minutes, especially on hard surfaces. They lean to avoid weight on the diseased gluteal area, sitting in a typical protective position on the affected side.

The diagnosis is made primarily through history and physical examination. Imaging and diagnostic injections help in the diagnosis. Initial non-surgical treatment with physical therapy, pain medications, and guided injections into the piriformis muscle. If there is no response, surgical treatment is indicated. It can be performed with traditional open surgery or endoscopically.


Posterior thigh muscle tendon injuries

Gluteal pain in the ischium bone (protruding bone in each buttock where we sit) is usually a result of injuries to the hamstrings tendons. This disease is the result of physical activities such as running in which the origin of these tendons in the ischium bone was broken. However, chronic, gradual ruptures also occur.

Isoofemoral Impact

This condition is caused by the narrow space between femur and ischium, which are impacted against each other in certain movements, causing local irritation and pain. Patients commonly complain of upper back pain, especially when trying to walk or run with long strides.

Pudging Nerve Compression

Gluteal, genital and sitting pain are some of the symptoms present in pudendal nerve compression. This nerve can be compressed at various locations from the pelvis to the genitals. Gynecological and urological surgeries are frequent causes. Endometriosis and vascular compression within the pelvis have also been described. Cyclists are at increased risk of this type of nerve compression, especially when using certain models of bicycle seats.

Lower back and intra pelvic problems

Diseases of the lumbar spine can cause gluteal pain and are the most frequent cause of sciatic pain, such as disc hernias. Ovarian and other intrapelvic organ problems are also possible causes of gluteal and sciatic pain.

The diagnosis of gluteal pain is complex. It is a deeply localized region with multiple sensitive structures. Well done physical examination and history are the basis of the diagnosis, always considering all layers of hip tissue as potential sources of pain.